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Dr. Atul Gawande on Real Healthcare Reform, Why Solitary Confinement Is Torture, and His New Book, “The Checklist Manifesto”

StoryJanuary 05, 2010
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We spend the hour with one of the most influential health policy writers in the country, Dr. Atul Gawande. He is an associate professor at the Harvard School of Public Health, a practicing surgeon at the Brigham and Women’s Hospital in Boston and a staff writer at The New Yorker magazine. We speak with him about an influential article on healthcare costs that was cited by President Obama and became “required reading” at the White House, healthcare systems in other industrialized countries, the effect of solitary confinement on prisoners, and his new book, The Checklist Manifesto: How to Get Things Right. [includes rush transcript]

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StoryJan 05, 2011Dr. Atul Gawande: Solitary Confinement is Torture
This is a rush transcript. Copy may not be in its final form.

SHARIF ABDEL KOUDDOUS: As Congress gets set to reconvene in the new year, the fight for healthcare reform is at the top of President Obama’s domestic agenda. The House of Representatives is scheduled to return from vacation on January 12th, and the Senate on the 19th. At issue for both chambers is how to merge the two bills that differ on substantial issues, issues that include financing and the inclusion of a public option, among many others. Democrats are hoping to get a final bill to the President’s desk before the State of the Union address in late January or early February.

AMY GOODMAN: Today we spend the hour with one of the most influential health policy writers in the country. Dr. Atul Gawande is a an associate professor at Harvard School of Public Health and is a practicing surgeon at the Brigham and Women’s Hospital in Boston. He’s also a staff writer at The New Yorker magazine.

We’ll talk to him about an influential article on healthcare costs that was cited by President Obama and became “required reading” at the White House, healthcare systems in other industrialized countries. We’ll also talk about the effect of solitary confinement on prisoners, that he’s written about, and much more.

But first, Dr. Gawande is just out with his third book. It’s called The Checklist Manifesto: How to Get Things Right.

Dr. Gawande, thank you very much for joining us.

DR. ATUL GAWANDE: It’s great to be here.

AMY GOODMAN: The checklist, what do you mean?

DR. ATUL GAWANDE: Well, in all of my writing, I’m interested in where the individual meets systems. And in medicine, what I’ve noticed as a surgeon is that we have become overwhelmed by complexity. We have trouble getting things right, because the volume of knowledge we’ve created in science has overwhelmed our ability as individuals to follow through. And we’ve seen ideas like “use a checklist” as a sign of weakness. We’ve not gone where aviation has gone in embracing these kinds of ideas. But for people on the receiving ends of care, they see the gaps, they see things falling through. And we’ve been slow to embrace some of these very simple ideas.

AMY GOODMAN: And what do you mean, the “checklist”?

DR. ATUL GAWANDE: Well, I tell the story of our effort to address the problem of deaths in surgery globally. Surgery is exploding around the world. People are living longer. And it’s not just infectious disease that’s now harming people. People need care for cancer, need care for auto traffic accidents. Quarter-million — —billion people get an operation each year, and we have over a million who die from complications; half, we know, are avoidable.

So what do we do? Our usual approach? More technology. Or train people longer and longer. I went through eight years of training to become a surgeon, and yet I still see mistakes every week. So we decided to try something new, which was a checklist. We worked with Boeing to learn how they made checklists for cockpits. We made a two-minute checklist for operating rooms. And when we implemented it in eight hospitals, ranging from rural Tanzania to Seattle and London, the average reduction in deaths was 46 percent.

AMY GOODMAN: Almost half.

DR. ATUL GAWANDE: Almost half. And, you know, I started using the checklist in my operations at Harvard only because I didn’t want to be a hypocrite. We were implementing this in lots of other places. But did I think I needed it? No. I haven’t gotten through a week where using a checklist that said, “Did we get the blood ready? Did we get antibiotics in? Also, does everybody in the room know each other’s name, so we’re working as a team?” -— we have caught problems at least once a week, sometimes every day.

SHARIF ABDEL KOUDDOUS: And why do you think this is so effective? You also tell the story of, at Johns Hopkins, how they implemented a checklist for a central line intravenous — inserting central lines. Talk about that and why, as you said, after eight years of training, something as simple as a checklist will help you avoid these mistakes.

DR. ATUL GAWANDE: Well, and I think this is where it connects with our thinking about this moment where we’re really trying to reform our health system. We’ve gone from a world where we thought penicillin is the kind of solutions we will have in medicine to a world where most of us will spend some time in an intensive care unit at some point in our lives. The average American will have seven operations over the course of time. And every one of these are incredibly complicated.

We’ve trained people under the assumption that what professionals need is to have it all in their heads, that we’re just going to remember everything. We now have 13,000 diagnoses, 13,000 ways the human body fails, 6,000 drugs, 4,000 medical and surgical procedures. We’re trying to deploy them community by community across the country. We’re having financial trouble doing it, and we’re having trouble making sure it’s safe and right. And that requires a new way of thinking, recognizing that we need some simple remedies, like checklists. If you have a new cancer, a new depression, why can’t we make sure we’ve identified the half-dozen things that we should make sure happen every time, no matter where you are in the country or, I would argue, in the world?

SHARIF ABDEL KOUDDOUS: And you write in the book — you go back to the 1930s and the development of a new type of bomber and really the transformation of the airline industry and of checklists. Can you talk about that story?

DR. ATUL GAWANDE: Yeah. This was the moment when we went from saying, “Hey, in aviation, whatever goes goes,” to recognizing that something needed to change. And that moment was in October 1935, when the Army had issued a request for new long-range bomber designs. Boeing came out with a design that put four engines on the plane. Before that, only — planes only had one or two engines. And so, this thing could fly higher, farther, faster, five times the payload of previous airplanes. It clearly was the plane they wanted.

There was a flight competition. This went up in the year and then immediately crashed, killed two crew members. They did an investigation. Nothing mechanically wrong with the plane. The pilot had forgotten to unlock the elevator controls that would allow the plane to level out, and so it just climbed and climbed until it lost air and crashed.

When Boeing lost this contract, nearly went bankrupt, but made half a dozen planes, pilots said, “We think we can fly this.” But their solution wasn’t, “Let’s throw more money at more technology,” or “Let’s train people for a gazillion years longer.” They just made a checklist, a before-takeoff list to make sure that nothing critical was forgotten. And with it, they flew almost two million miles without a single mishap. We’ve hit our moment — well, what they recognized was that plane had become too much airplane for one person to fly.

We’ve hit that moment in a lot of components of our society. We’ve hit it in medicine. We’re hitting it in fields like how do we deal with homeland security. And our troubles are that we don’t try to learn, we don’t try to understand how you make teams work well. And there’s a science to this. There’s not just a science of discovery. There’s a science to how to make sure people at the front end know how to do the best possible things for people.

AMY GOODMAN: We’re going to break, and then we’re going to come back to this discussion. Our guest is Dr. Atul Gawande. He is a surgeon at Brigham and Women’s Hospital in Boston, and he’s the author of a new book called The Checklist Manifesto: How to Get Things Right.

This is Democracy Now!, democracynow.org, The War and Peace Report. We’ll be back with him in a minute.


AMY GOODMAN: Our guest for the hour is Dr. Atul Gawande. He’s a surgeon at the Brigham and Women’s Hospital in Boston, and he writes for The New Yorker magazine. His latest book is called The Checklist Manifesto: How to Get Things Right.

And we’re talking about checklists right now. From the plane to the first story you tell in your book, about a man who came in with what, well, doctors thought was a stab wound.

DR. ATUL GAWANDE: Well, and it was. He was at a Halloween party in the middle of San Francisco, arrived in a hospital doing — he’s stable, doing well. They did the standard, search him head to toe, found a single two-inch-size wound in his abdomen. Vital signs were OK. He was feeling OK, drunk and babbling.

And the trauma team has a choice at that point. You either get proper imaging, you go through their medical history and make sure you haven’t missed anything, or you rush straight to the operating room because this person could die on you right now. Well, he was stable, and given a stab wound that didn’t look too bad, they decided to go through with imaging. And then, five minutes later, he crashed right in front of their eyes. He lost his blood pressure and started to die on them. They then switched gears, rushed him back downstairs, and it was all they could do to save him. He was in the hospital for over a week from a stab wound that turned out to have gone through his belly — he was over 200 pounds — almost a foot-and-a-half through him into his aorta and lying in the back of his body.

And a surgeon who was there had been a surgeon in Vietnam, and he said, “I hadn’t seen a wound like this since Vietnam.” And it turned out he was right. They learned afterwards they forgot to ask one question: What did the weapon look like? Turned out he was at a Halloween party where the other guy was dressed as a soldier and stabbed him with a bayonet. And if they had been able to not miss that one question — what does the weapon look like? — they would have figured out this was a much more dangerous wound.

I tell that story because there are a thousand ways that things go wrong in a complex world like in medicine. And we have had a hard time trying to grapple with the reality that the knowledge is beyond the capacity of any one person to hold it in their head. There are technologies that we’ve tried to introduce. We’ve pursued very expensive solutions. But what we’ve not recognized is that we can pursue an idea like checklists, the way airlines have it. We should have a checklist for virtually every high-risk step that we have in medicine. We should identify what the best practices are and how to make them usable at the front lines.

And we’ve forgotten that this is part of the science of what it means to make better healthcare and lower cost. The surgery checklist we came up with for operating rooms cost us less than a million dollars to create and test in eight hospitals around the world. And the savings that come from actually implementing it in our hospitals would be greater than $25 billion if we use it.

But we’ve also had a cultural resistance. There are less than 20 percent of American hospitals that have adopted the surgical checklist that we’ve got. Interestingly, in health systems that have national healthcare, they’ve moved faster to adopt it. France, just four weeks ago, went live in all 8,000 of their operating rooms, with surgeons using the checklist to reduce harm in care.

SHARIF ABDEL KOUDDOUS: I want to read to you from an article published in the British medical journal The Lancet

last August, and it’s co-written by a number of people, one of them Peter Pronovost, whom you credit in the book for creating the checkline — I’m sorry, the checklist for central line infections. And they’re talking about the Michigan Keystone ICU initiative.

And this is what they write: quote, “The problem is that the story may well have been oversimplified.” They’re talking about the media coverage. “The emphasis on checklists…is a distraction from the plot that diverts attention from how safer care is really achieved. Safer care is achieved when all three, not just one, of the following are realised: summarize and simplify what to do; measure and provide feedback on outcomes; and improve culture by building expectations of performance standards into work processes,” they say. They go on to say, “We propose that widespread deployment of checklists without an appreciation of how or why they work is a potential threat to patients’ safety and to high quality care.”

What’s your response to that?

DR. ATUL GAWANDE: They’re completely right. Part of what’s fascinating about the checklist idea is, if we just drop tick boxes into place and you have people just going to their paperwork and not thinking about the patient, we’ve not solved the problem. There are good checklists and bad checklists. There are ones that turn people’s minds off and become central command and control. This is about making teams having an aid that actually makes them more effective and not forgetting the dumb stuff.

And then, second, we do have a culture issue here. We see it, in medicine, as a form of weakness. You see a doctor in the office, and imagine if the doctor said, “Hmmm, let me look this up in a textbook and pull the textbook out.” You lose confidence in them. We want to pretend we are infallible.

AMY GOODMAN: I gain confidence in the person.

DR. ATUL GAWANDE: Exactly. That we have got to — we’ve now started to recognize that we actually are better off saying to people, “I could get this wrong, and we need to check on it.” But what he points out is, just creating a checklist that simplifies what needs to happen in every office appointment doesn’t mean people use it. It does not mean that we have changed our culture to recognize that we are in the midst of redesigning our system.

AMY GOODMAN: Sharif mentioned the Michigan system and the test that was done there. I was fascinated by what some of the poorest hospitals in the country did in Detroit. Talk about what the adoption of the system — what it meant and what it meant for the doctors there, in the hospitals that could least afford any kind of change, some might have argued.

DR. ATUL GAWANDE: Yeah. We have two million people who pick up infections in hospitals in the United States, because somebody didn’t wash their hands. And so, for — and one of the most common infections, in intensive care units, where the intravenous lines get inserted. What was recognized, that if you made a checklist that said, before the line goes in, that you’ve made sure: everybody has washed their hands; a hat, mask, glove, gown is on; sterile drapes are on the patient; soap to clean the site had gone in — that this would reduce their infections. And when they put it in place, it reduced their infections in the state of Michigan by more than two-thirds. The average hospital in Michigan has zero infections now from these kinds of lines in any given quarter. The worst hospital in Michigan has a lower infection rate than 90 percent of American hospitals.

AMY GOODMAN: Which hospital is it?

DR. ATUL GAWANDE: Well, at this point it’s not clear which one is the worst. But I visited Sinai-Grace Hospital in inner city Detroit, one of the most depressed, struggling public health systems in the country, that had managed to improve their infection rates, under struggling conditions of poor resources, in extraordinary ways.

And what’s interesting about it is, to make a checklist like this work, it requires a shift in power. What it means is allowing a nurse to tell a doctor, “I think we didn’t finish all those five steps that we have to go through.” And there comes a moment when the doctor will then say, “I’m the doctor, and I decide what goes on here.” And if an administration doesn’t back them up and say, “The culture of our hospital has changed. We have a team, and the nurse can actually say, ‘No, wait a minute, this is a moment that we have to halt because we could harm someone,’” — a lot of these ideas are around creating the power for a group of people to work effectively.

AMY GOODMAN: One of the examples you give in that Detroit case is that they included in the central line kit, after a while, soap or the antiseptic.

DR. ATUL GAWANDE: Yeah, it’s one of the — one of the bizarre things, that you then work backwards. You realize, you know, of course it’s frustrating at the frontlines delivering care, because if you want to follow through on those five steps — for example, putting soap to clean the site where the line goes in, the proper soaps weren’t actually in the kits. You needed people at a system level to go back to the manufacturers and say, the best care requires the right size drapes, the right kind of soap, and it’s not in there. And that kind of change wasn’t possible until you decided as a state, this is what we have to do right.

SHARIF ABDEL KOUDDOUS: Dr. Atul Gawande, I just want to switch gears for a moment here. In addition to being an author, a practicing surgeon and a professor at Harvard Medical School, in your plenty of spare time you’re a staff writer at The New Yorker. And many of your articles have been very influential, perhaps none more so than one you wrote in June about health costs in McAllen, Texas. It was — became apparently required reading at the White House. President Obama convened a meeting of his aides to discuss it. He cited it in a speech before the American Medical Association. Talk about what you found in McCallen, Texas, where it had the highest cost of healthcare in this country, and what that meant for health reform in this country.

DR. ATUL GAWANDE: I didn’t really understand what we needed to do to control costs. We’ve had solutions about what to do about coverage for three decades, that you could almost pull off the shelf, and we’re arguing about which one we want off the shelf. But what do you do about cost?

I decided the way to try and answer this was look at the county that’s spending the most money in the United States for healthcare, for Medicare. And that was in South Texas in McAllen, Texas. And I visited doctors there, and I said, “What do you think is going on?” I compared that county, which is a border county, very poor, one of the poorest counties in our country, large Spanish-speaking-only population, you have a high rate of undocumented immigrants — but El Paso, Texas is just the same. And El Paso costs half as much per person for healthcare. And so I said, “What was the difference here?”

And some of the answers that they gave me were alarming. There were massive numbers of physicians, large numbers of physicians, who were now buying up their own imaging centers, surgical centers. And what they were describing to me was a world where medicine had become a business, where the desire to — there’s always, in any system, a conflict between the way you can make money and the way you can take good care of patients. And the incentives in our healthcare system as a whole have been screwy. With a fee-for-service system, if you do more, you get paid more. That leads to more surgery, more radiology. And you saw it in McAllen. They were doing twice as many heart operations, twice as many pacemaker placements. And home healthcare spending was through the roof. There was a sense in which the culture of medicine had gone to an extreme that we don’t want to approach as a country.

The startling thing to me is not that this was McAllen, Texas; it was that they were basically following the incentives of our healthcare system to its logical limit. And the remarkable thing is that other places haven’t done it yet. We could become a place that is like that, unless we change our incentives to be about not more care, but better care; if we don’t think hard about the kind of care we want to deliver, which includes what are the things that we want to have at the bedside; and also if we aren’t thinking about our culture in medicine, which can be corrupted.

AMY GOODMAN: Well, explain what it is that caused this major difference just between, for example, McAllen and El Paso. What you discovered were these incentives for some of the most expensive healthcare in the country, I think, which shocked people all over the country, in McAllen, Texas.

DR. ATUL GAWANDE: Yeah, and the surprising thing was that the incentives were not remarkably different there, but you had some members of the medical community who started to recognize the opportunities. So you had a large for — you had for-profit hospitals, a large physician-owned hospital. You had fragmented, disorganized care. And so, what that meant — and then you looked in certain pockets, like mental healthcare. It’s low profit, it gets neglected. Primary care, again, not as — what you saw were big cardiology centers, orthopedic centers. The parts of medicine that — we want great cardiac care, we want great orthopedic care, but not at the neglect of the whole system of care, that was missing.

AMY GOODMAN: So the doctors were making more money there?

DR. ATUL GAWANDE: They were. I don’t have the numbers, but let me put it this way. One of the stories that I tell is of a — is of the contrast. And I talked about Grand Junction, Colorado or the Mayo Clinic, where you could have a higher quality care at much lower cost, and how it actually is possible in our country. A third of the places are delivering this. And one of the things that you see in those places, the care is better organized. They actually work on making sure that inappropriate care, even if it makes high profit, doesn’t happen.

And when the article was written, teams from McAllen actually went to visit one of the lower cost places, which I see as part of what reform is about — changing things. But one of the folks in Grand Junction, Colorado called me up to say, “You wouldn’t believe it, but these doctors arrived in a private jet.”

AMY GOODMAN: I mean, you point out that the Mayo Clinic doctors are on salary.


AMY GOODMAN: That’s a massive difference.

DR. ATUL GAWANDE: It is. And one of the things that we don’t know is — a salary doctor, we know, doesn’t have the incentives to just do more and more and more. On the other hand, we’ve seen that a salary doctor could be someone who goes home at 2:00, because, hey, the day is over, and I want to go. We’ve seen systems, though, where they have doctors who are even on salary and as a — and have created higher quality care, hardworking organizations that really provide extraordinary care.

I don’t know if the answer is switch everybody from fee-for-service to salary. What I do know is that we need a different way of paying doctors than the piecework kind of way we’ve got. And the reform bill that’s now under consideration, for the first time, actually starts to tinker with that system, to say we will give incentives to places that begin trying new ways of paying doctors and testing them for both the effect on reducing cost and its effect on improving quality.

SHARIF ABDEL KOUDDOUS: And I think one of the most startling things you write in the article is that not only do they do these unnecessary tests, but it can actually be harmful to the patient. More testing can actually result in worse care.

DR. ATUL GAWANDE: Yeah. When we — we are now a country that does over 50 million operations a year. I’m a surgeon. I like doing operations. But when you start doing more than 50 million operations a year, you better be sure — for a country of 300 million people, you better be sure we’re doing the right ones. And we know, in certain pockets of care, we’re producing more surgery than we should. And if you do excessive amounts of surgery, we have major complications.

We have right now over 150,000 people who die of complications of surgery, die within thirty days following surgery. And we know at least half are avoidable. If we are able to think harder about making sure we’re providing the right care in the right ways and avoiding overtreatment and mistreatment, we are likely to actually be better about saving people’s lives and improve our cost picture considerably.

SHARIF ABDEL KOUDDOUS: And you talk about incentives and having a correct system in place. Do you think that private insurance companies have a place in healthcare in this country? I mean, they have a legally obligated — obligation to increase their profits, and that almost necessarily implies denial of care. There seems to be an inherent conflict of interest. How do you resolve that? Do you think we should get rid of private insurance?

DR. ATUL GAWANDE: One of the things about my article about costs was that I found myself almost not having to think about or not addressing insurance at all, because whether it’s Medicare or other public health government programs or private insurers, none of them have figured out how to keep our costs under better control. It really has to do with the decisions that doctors and patients make together, about “Do I get a scan for this headache? Do I get an operation for this back pain? For my eighty-five-year-old father or mother with a — with dementia, but a tumor, should we take it out or not?” Those questions are fundamentally medical. I don’t think insurers, public or private, are likely to be the source of the solutions.

But what I can tell you is that as we go through reform to remove their ability to cherry-pick on preexisting conditions or shove people out of care, it forces this key question: What is the value added by having private insurers? The only place it can be added is if they are working to improve care and control costs, work that hasn’t been done in a significant way on either side.

SHARIF ABDEL KOUDDOUS: And you also talk about the Massachusetts plan. Can you explain what that is?

DR. ATUL GAWANDE: And I’ve been living through it. The Massachusetts plan has — we had 12 percent uninsured two-and-a-half years ago. We adopted a bipartisan plan that allows people to get a choice of private insurers, and it actually doesn’t look that different from the reform plans going through now. That choice of insurers, you can go online and pick up coverage that’s subsidized, so that nobody pays more than eight percent of income, and if you’re poor, it’s free.

That provision of insurance has changed things dramatically in the last two years. We have only two percent uninsured. It’s like many European countries now. The people in the state haven’t really noticed it. And the claim that this is going to bust the budget of the state just hasn’t come to fruition, no matter how much the blogs say one way or the other. The data are that health costs in the state have risen at the same rate as in other states. And in this recession, we didn’t have the bottom fall out from our families under it. The cancer patients I had to take care of, where we spent half our time trying to figure out how to get them coverage, I haven’t had that happen in two years.

AMY GOODMAN: I wanted to get your comment on one of your colleagues, Dr. Steffie Woolhandler, professor of medicine at Harvard University, primary care physician in Cambridge, co-founder of Physicians for a National Health Program. We spoke to her in September and asked her about the Massachusetts plan that includes the individual mandate.

    DR. STEFFIE WOOLHANDLER: When the individual mandate was rolled out this past year, we saw no improvement in the number of uninsured in the state. We actually saw a deterioration in access to care. The previous year, they had rolled out a Medicaid expansion. That worked. That got some people covered. But when they rolled out the mandate this year, there was no improvement in the number of insured.

    The Census Bureau just announced that only — that only half of the uninsured were covered by that Medicaid expansion. It also found that there were five-and-a-half percent of people in the state uninsured. That’s not universal coverage. And then, our private insurance industry just announced that they’re raising all of our premiums ten percent, and they’re saying that’s because of the cost of the reform.

    So, in Massachusetts, we’ve spent a lot of money. We’ve managed to cover about half of the uninsured through Medicaid expansion and expansion of Medicaid-like programs. We’ve given the insurance industry absolutely everything they wanted. And what we’re getting is higher prices and still having uninsured people in the state.

AMY GOODMAN: That’s Dr. Steffie Woolhandler. And Physicians for a National Health Program have come out against the Senate bill, said don’t support it, like Dr. Howard Dean has. But your comments on her assessment of your plan in Massachusetts?

DR. ATUL GAWANDE: Yeah, Dr. Woolhandler and I disagree on this. And the numbers that have come out over the last couple years have really shown a dramatic change. By the most recent numbers — and it’s been confirmed again after a year — we’re down to two-and-a-half percent uninsured. At a time when the recession dramatically ballooned the rolls of uninsured in every other state, Massachusetts went in the other direction.

And then, the idea that the costs have gone up? They have. They’ve risen about eight percent, just like every other state in the country. The reform plan in Massachusetts did nothing on cost. It didn’t explode the budget to do something about the uninsured.

It is providing care in ways that are making dramatic differences in people’s lives. And I see it. I had a nineteen-year-old patient two-and-a-half years ago who had a metastatic cancer. I’m a cancer surgeon. We did the operation. She had college coverage. It capped out at $75,000. And then we were scrambling for chemotherapy and radiation. And she forwent it for almost a year, because she didn’t want her family to deal with the cost. I haven’t seen a case like that in two years. It is dramatic. And I think we can’t lose sight of that public health value.

The reform bill underway, though, does begin to do much more about cost, including addressing these problems that I really saw as the core of what’s going on in McAllen: How do we create a different way of paying physicians and hospitals so that we’re now — have the reasons — we’re paid not for quantity of care, but actually for getting better results.

AMY GOODMAN: We’re going to go to break. Then we’re going to come back. Dr. Atul Gawande is our guest. His book is called The Checklist Manifesto: How to Get Things Right. I want to talk to you about your research on the other countries in the world and the systems they have, and then very interesting piece you wrote on solitary confinement, on the effect on human beings as social animals.

This is Democracy Now!, democracynow.org, The War and Peace Report. We’ll be back in a minute.


AMY GOODMAN: Our guest for the hour, Dr. Atul Gawande. And we’d like to get your comments, as well. You can email us questions or comments at stories(at)democracynow.org. Dr. Gawande’s latest book is called The Checklist Manifesto. He’s a staff writer at The New Yorker magazine. He’s a cancer surgeon at Brigham and Women’s Hospital. He’s at Harvard, as well.

Dr. Gawande, the other countries that you’ve looked at and the systems that they have, from France to Australia to Britain to Canada, how do they compare to the United States?

DR. ATUL GAWANDE: They have much more equitable coverage. And that’s a —-

AMY GOODMAN: They have much more…?

DR. ATUL GAWANDE: Equitable coverage. That’s a fundamental value that they’ve embraced, long before we have, that everybody would be covered for care.

Second of all, they have been able to organize care in ways that we’re seeing, for example, service. In most of Europe, there are evening hours for primary care physicians. And that’s not something we have here. Most of the systems have -— in Europe, have computerized records, which has allowed them to work on improving safety and being able to make sense of care in ways that work with cost.

There are aspects of care that are not as good. We are very good in management, for example, of cancer care, and they’re taking lessons from us. So I’m not going to say that things are perfect, but our unwillingness to learn from other examples will hurt us in the long run.

AMY GOODMAN: What do you make of the media’s vilification of anything other than we have so that people can’t make a rational assessment? You’re making a political decision everywhere else. “Do you want to be a socialist, or do you want to have good medical care?” is basically the question.

DR. ATUL GAWANDE: Yeah. And my only way to go at it is to say, let’s just solve problems. In our surgical work, we said, “Show me ideas from the best systems in the world of the what the way care should be.” And what we identified were nineteen steps that were the kind of best practices. And some came from, you know, our hospital at the Brigham and Women’s Hospital, Johns Hopkins, Toronto, but also got some ideas from Tanzania, from New Delhi.

AMY GOODMAN: Like what?

DR. ATUL GAWANDE: In our checklist, for example, we had learned that there were systems in other parts of the world where we make sure that everybody in the room is introduced by name. And that improved the likelihood that the team actually function as a team and a nurse could speak up when they recognized a problem, that they felt they had the voice to be able to say, “Stop for a second.”

So when we created this, we said we’re just going to take the best ideas, implement them, and then we implemented them, not just in the United States. We wanted to see, does it matter in Toronto, does it matter in Jordan, does it matter in Manila. And everywhere we put the system in, we reduced complications and deaths by double-digit figures.

AMY GOODMAN: How did other countries develop their systems?

DR. ATUL GAWANDE: You know, it’s always by a hodgepodge. We think that, you know, Britain got its totally government-run system, or France its largely union-developed system, or Switzerland its entirely private insurance system, because a bunch of people sat in a committee room and said, “What’s the best system we could come up with?” Instead, it has been through historical accident, over and over again.

World War II led Britain to — under the bombing attacks from Germany, to have to shift its entire population to the rural countryside. If they were going to survive, the government had to build hospitals. And suddenly they went from a private health system to a government system because of war requirements. And so, it was Churchill, the conservative, who led the campaign saying, “Let’s have — let’s make sure we have coverage for people, and let’s build on the system we have.” Well, the system they had was government coverage.

SHARIF ABDEL KOUDDOUS: And what about the issue of single payer in this country? You write about that, as well, in this article, talking about France, looking at Great Britain. There has been — single payer was off the table from the beginning of the conversation about healthcare reform in this country. Do you think that’s the way to go?

DR. ATUL GAWANDE: I’m not inherently against single payer, but I’m — my questions have always been not about what is our idealized system, but how do we get there from here.

AMY GOODMAN: And explain what you mean by “single payer”?

DR. ATUL GAWANDE: “By single payer” would mean having a single government-run insurance program, Medicare for everybody. That would be single payer. And as a physician, all I can tell you is I don’t care if it’s Medicare for everybody, a group of private insurers; it is better than what we have now, which is a mess and is not leading to better care or sense about how we’re handling costs.

The fact that we’re taking steps forward and organizing ourselves — we’re a country where we’ve been a mixed model. We’ve had about 50 percent of the country is on government programs like Medicare and Medicaid, and about 50 percent on private insurance. And in each system, people are mainly fearful of losing what they have. And addressing that fear of losing what they have is what is at the core about reform. And as we build forward, this is going to be a test, over time, which system will serve people the best.

AMY GOODMAN: Do you think we could get to a single-payer system from what is being proposed now in Congress?

DR. ATUL GAWANDE: Yes, it’s very possible.

AMY GOODMAN: How? What would that road look like?

DR. ATUL GAWANDE: The road, I think, is that we are now moving to a system of such significant insurance regulation that the insurance role of cherry-picking risk gets replaced with an insurance role of organizing care. And we have a Medicare system and Medicaid system that are trying to do the same thing.

Over time, what we’ll learn over the next decade is which system is helping drive better costs, which system is better organizing care. And what I think we’re going to find is the most effective systems probably don’t look a lot like Medicare and don’t look a lot like Aetna or United. They look a lot more like — Grand Junction, Colorado is dominated by a local insurer called Rocky Mountain Health Plan. And because it’s local and they have feedback to know what the needs of their population are, they’ve been able to work in ways that have doctors, community people, employers all on the same side working to have a system that makes more sense. And it’s resulted in higher quality and lower cost.

AMY GOODMAN: Let’s talk about solitary confinement.

DR. ATUL GAWANDE: Yes, other article I wrote.

AMY GOODMAN: Yes, a totally different issue, extremely important. Talk about your findings.

DR. ATUL GAWANDE: And to me, at some level, these are not different issues. I mean, this is about what we think of ourselves as individuals facing large systems. And what bothered me about solitary confinement was that this is a generational change. We have —- we barely use solitary confinement, even during the Reagan years. But during the last decade and a half, our use of solitary confinement has exploded. We have over 50,000 people now in long-term solitary confinement. It dwarfs the experience of any other country in the world. And what -—

SHARIF ABDEL KOUDDOUS: What do you mean by “solitary confinement”? Explain the actual circumstance of it.

DR. ATUL GAWANDE: It is just as you imagine it: small cells, usually about ten feet by twelve feet or so, people confined and limited from having any social contact, maybe in some places an hour or so a day in a fenced-off area. I describe one set of cells where there’s — they call it “the kennel,” because they literally put people out into dog kennels, runs that let them get a little outdoor time, but basically twenty-three hours a day of total isolation, and in many instances, situations where you have no social contact with people for months on end, even with visitors or family.

And what I did was I looked at the experience of hostages — John McCain, who spent years in solitary confinement in Vietnam, Terry Anderson, the journalist who was kidnapped in Lebanon. And their experience, the science of what happens to people deprived of social contact, is they have to fight for their sanity. And many lose their sanity. That reality, that we are social beings in our physiology, led me to ask the question, is solitary confinement, the way we’re practicing it now, torture? And you can’t read the cases — and I describe the cases of both hostages and people who are in prisons — and conclude that, number one, those experiences are different. They’re the same. Number two, you can’t conclude that it’s not torture.

SHARIF ABDEL KOUDDOUS: What happens exactly? I mean, there’s a physical change in the brain. Explain.

DR. ATUL GAWANDE: Yeah. They, physicians, took people who were confined in Serbia in concentration camps under conditions of isolation, and some of them were not in isolation, but beaten. And they did brain scans, and they found that people who had sustained head injuries had the same degree of brain injury as people who had sustained solitary confinement for long periods.

AMY GOODMAN: I want to bring up a case, ask you about the case of Syed Fahad Hashmi, a young US citizen who’s been held in twenty-three-hour-a-day solitary confinement for nearly three years. He’s charged with providing material support to al-Qaeda in a case that rests on the testimony and actions of an old acquaintance who turned government informant after his own arrest. Hashmi’s period in solitary confinement is believed to be one of the longest ever for a prisoner before trial.

We spoke to his brother Faisal last summer. This is how he described the prison conditions of [Syed Fahad] Hashmi, who’s really just down the road from us right here in New York.

    FAISAL HASHMI: He has not gone to trial. He’s a pretrial detainee. In a civilized society, a pretrial detainee kept in complete solitary confinement for two years. Within his own cell, he’s restricted in the movements he’s allowed to do. He’s not allowed to talk out loud within his own cell. So, imagine for yourself, you’re a pretrial detainee, not convicted of anything, and you’re held in these conditions where you’re not allowed to move, not allowed to talk.

    AMY GOODMAN: What do you mean, “move”?

    FAISAL HASHMI: Certain movements within his own cell are censored. He is being videotaped and monitored at all times. He can be punished, more than he’s already being punished, by denied family visits, if they say his certain movements are martial arts or something that they deem as incorrect.

AMY GOODMAN: This is Faisal, the brother of Fahad Hashmi, who is in prison here, pretrial detention, three years. He described how when he tried to exercise, to do martial arts, he was told he could not get in those positions. What is the physical effect on the brain of this level of solitary confinement?

DR. ATUL GAWANDE: Yeah, what we have observed — and we’ve learned this from both hostages and from prisoners — is that you, first of all, you begin to lose the speed of thinking. You slow down to the point of needing sleep for hours a day and yet being tired. And then it advances to a point where you can dissociate, you begin losing touch with reality. One prisoner I spoke to, for example, after three months, you’re allowed to get a television, which he looked forward to as a chance for maybe a kind of social connection in the world. But by that point, he found the television was talking to him, asking him to kill people, and he had to stow it underneath his bunk just to be able to survive and live through this.

There’s no question that many of the people we confine are violent or threatening people. The vast majority of people in solitary confinement, though, are not people — and bipartisan commissions have shown this now for a while — are, the majority, not people who are that incredibly violent. We also learned from the British experience, where they found the solitary confinement of our IRA prisoners produced both mental damage and such torturous conditions that actually turned public sentiment against the government in that process. And so, Britain went to a process of phasing out solitary confinement. They have just as much troubles with violence in their country and in their prisons, and yet they have fewer than a minuscule portion of their population in solitary confinement.

And the last part of it is, solitary confinement is unbelievably expensive. Managing it is three to four times as expensive. And in these moments, we have found ourselves crowding prisons larger and larger. Of course that breeds more violence. And then that leads us to say, well, we should then put folks in solitary confinement. And we’ve caught ourselves in a vicious circle, to the point that prison commissioners I talked to would only speak to me anonymously about this, because they would get fired for saying it. But they thought solitary confinement should end.

AMY GOODMAN: We’re going to leave it there, because the program has come to an end. Dr. Atul Gawande, we want to thank you very much for being with us. His latest book is The Checklist Manifesto: How to Get Things Right. Dr. Gawande’s writings are in The New Yorker magazine. He is a surgeon at Brigham and Women’s Hospital in Boston, and he also teaches at Harvard.

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Dr. Atul Gawande: Solitary Confinement is Torture

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